Club Busy Bee Online Registration

Registration

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Welcome to Club Busy Bee! Please complete the following registration form. Please read the following: 1. If you want to start your child at a later date, you must email us at info@clubbusybee.org and let us know. 2. There is a NON-REFUNDABLE annual registration fee for each child enrolled in the following programs: - AM Only - PM Only - AM & PM 3. If your child has food or drug allergies, you MUST complete an Allergy Emergency Plan or your child will not be able to attend.

* denotes required fields

Referral Information

How did you hear about us?

Referral Name

Family Information

Family Last Name*

Where do you live?

Home Address*

City*

State*

Zip*

Primary Phone*

Additional Info

Emergency Contact Name*

Emergency Contact Phone #*

Emergency Contact Address*

Contact #1

Person authorized to pick-up your chid First Name*

Last Name *

Type

How Can We Contact You?

Home Phone *

Work #

Cell #

Portal Access (your email is your login)

Email* (Emails are kept confidential)

Confirm Email*

Portal Account Password

Confirm Portal Account Password

Contact #2

Person authorized to pick-up your chid First Name

Last Name

Type*

How can we contact you?

Home Phone

Work #

Cell #

Email (Emails are kept confidential)

Confirm Email

Student #1

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size

School*

Grade Level*

Disabilities*

Special Needs*

Allergies*

Medications*

Primary Doctor Name, Address, & Phone*

Please click on the Search button below, then choose your campus.

Enroll in Classes

Select Class *

Student #2 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size

School*

Grade Level*

Disabilities*

Special Needs*

Allergies*

Medications*

Primary Doctor Name, Address, & Phone*

Please click on the Search button below, then choose your campus.

Enroll in Classes

Select Class

Student #3 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size

School*

Grade Level*

Disabilities*

Special Needs*

Allergies*

Medications*

Primary Doctor Name, Address, & Phone*

Please click on the Search button below, then choose your campus.

Enroll in Classes

Select Class

Student #4 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size

School*

Grade Level*

Disabilities*

Special Needs*

Allergies*

Medications*

Primary Doctor Name, Address, & Phone*

Please click on the Search button below, then choose your campus.

Enroll in Classes

Select Class

Student #5 (Show-Hide Details)

Student's First Name*

Last Name*

Student Gender*

Birth Date*

Additional Info

T-Shirt Size

School*

Grade Level*

Disabilities*

Special Needs*

Allergies*

Medications*

Primary Doctor Name, Address, & Phone*

Please click on the Search button below, then choose your campus.

Enroll in Classes

Select Class

Add Another Student

Required Policies and Agreements

(Show-Hide Details)

Questions or Concerns

Comments

Payment Information

Credit Card

Card Number

Exp Month

Exp Year

Card Nickname

Name as it appears on card

Address Line 1

Address Line 2

City

State

Zip

eCheck/Bank Draft

Bank Name

Account Type

Your Account Name (Your name on your bank statement)

Bank Routing Number (9-digit number)

Account Number

Registration

Referral Information

Family Information

Where do you live?

Additional Info

Contact #1

How Can We Contact You?

Portal Access (your email is your login)

Contact #2

How can we contact you?

Student #1

Additional Info

Enroll in Classes

Student #2 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #3 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #4 (Show-Hide Details)

Additional Info

Enroll in Classes

Student #5 (Show-Hide Details)

Additional Info

Enroll in Classes

Required Policies and Agreements (Show-Hide Details)

I Agree to All of the Above

Questions or Concerns

Payment Information

Credit Card

eCheck/Bank Draft

Required Policies and Agreements

(Show-Hide Details)